Director,Utilization Management Compliance

Responsible for developing, integrating, implementing and monitoring compliance with the Utilization Management Plan including policies and procedures across health plans, NCQA and other regulatory agencies. Serves as a liaison between the medical group and the governing agencies in accordance with the Office of the Medical Director/Quality Management Sessions (OMD/QS). Works as a cross-functional team member with Care Management, Quality Improvement, Risk Management, MCA and Contracting.

ESSENTIAL FUNCTIONS:

Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.

Responds in writing to all health plan UM requests and determines how best to meet these requests.

Manages, coordinates and facilitates annual health plan audits of components within the HCP corporate and network organizations. Responds in writing to correct any deficiencies.

Assists and facilitates consistency and compliance of Care Management in accordance with health plan, CMS and NCQA requirements. Assists and makes recommendations for any revisions to the UM plan to meet these requirements.

Assists the Regional Care Management departments in the development of the appeals/denials process. Facilitates consistent policies and procedures throughout the organization.

Coordinates the submission of the health plan UM quarterly reports in a timely manner.